Following your Path

Leading the journey: Engaging staff in process improvement through visual management

The pressure is always on in busy clinical settings to improve efficiency, capacity, and patient flow. Strategic process improvement that engages the entire staff is essential to keeping up with demand while addressing quality and safety.

The staff of the Inova Alexandria Hospital’s Endoscopy Suite, Alexandria Virginia, has taken a truly transformative process improvement journey. It not only improved processes and outcomes—it changed individual staff in a very positive and profound way.

A key tool used by the busy gastroenterology clinic for process improvement is the True North Wall. This is a visual management tool that helps keep process improvement initiatives in view of the frontline staff. The theory behind visual management is that if goals and information are in plain sight, they are easy to remember and keep in the forefront.

The True North Wall communicates important priorities of the organization and its clients. It also provides data about how the department is performing. Providing consistent visual cues allows the entire staff to share the same information and vision for improvement.

The design and layout of the True North Wall allows for quick recognition of information in an efficient and clear manner. It is located in a visible location in the department so staff can easily review it every day.

The True North Wall consists of a formal organized communication board designated to showcase process improvement projects with the data that supports the improvement. Information presented on the wall includes:


  • A Creative Solution Board designed to encourage staff’s input on a “need to act” within the department
  • Service, satisfaction, and affordability with overall hospital operational data
  • Identified departmental process opportunities in service, satisfaction, and affordability with measured data.

The board can be updated easily to provide staff with real-time feedback regarding performance. Over time, the data presented on the board shows trends that help them see how their performance has changed. This aids staff to evaluate change, maintain change, and look for opportunities for more improvement. It also helps them see actions that are needed so that issues don’t repeat themselves.

Taking your team on a successful process improvement journey

The True North Wall is only a tool that facilitates process improvement. To be effective, it must be integrated into a comprehensive process improvement program. This can be quite a journey for staff, so how does one get started? Host a Kaizen event. This activity involves the entire staff, in collaboration with a facilitator, to study a process then select and pilot a small test of change.

The staff at Inova Alexandria Hospital’s Endoscopy Suite assembled a team to map the patient throughput process and identify issues and opportunities to improve patient flow. The team decided to focus on improving efficiency from the time a patient posts for a procedure through discharge from the outpatient clinic.

The Kaizen event helped the team identify an idea for change that would likely produce a rapid improvement. Staff decided to increase the number of patient phone calls to obtain pre-procedure histories. They selected two key patient history items: medication reconciliation and allergy inquiry.

The team hypothesized that if they could document all meds and allergies ahead of time, they would decrease time spent during the face-to-face assessment on the day of the procedure. They believed that this would improve patient flow, resulting in a better patient experience, and enhance physician and staff satisfaction.

The True North Wall provided a continuous visual guide during the pilot project. Information provided on the wall included daily metrics regarding real time performance. Seeing this information on the wall everyday kept the team on track and maintained a collective vision during the pilot project.

Seeing the change

The results of the team’s efforts speak for themselves. The physicians noticed a profound improvement in efficiency in patient flow. Results like these have led to a renewed commitment of all physicians and team members to partner in continuous improvement. The staff also remark about improved morale and team effort that is supported by their medical colleagues. The reduction of overtime, the ability to have an adequate meal break, and the opportunity to improve patient satisfaction with procedures starting on time has increased their personal satisfaction.

The staff even suggested hosting a physician appreciation dinner to celebrate the successes and highlight the next steps in engagement. The dinner was a tremendous success, well attended by staff, physicians, and administration. During the dinner, one physician applauded the efforts of the team and stated that the efficiencies in throughput were the best he has ever experienced.

 The next step

The success of the pilot project helped the staff understand that they must continue to take ownership of process improvement. For example, they decided to improve communication—and showcase their efficiency—by making a friendly “your patient is ready” call to the physicians for the first case of the day. This has helped ensure that everyone—staff and physicians—stays on schedule.

Results of this step included more on-time first-case starts and faster room turnaround. For example, the on-time first-case starts improved from 15% of the cases per day to 35% of the cases. The room turnaround times decreased by 36%.

Staff also instituted a debriefing session after every first case of the day to celebrate the on-time start or to discuss the cause of the delay. This provides data about issues that can be studied for improvement.

Because of this process, overtime has been reduced by 86%. Staff also says that they have a better sense of control over the schedule, which now allows time to plan for the next day. Physician satisfaction also has improved dramatically. All eight physicians surveyed strongly agreed or agreed that they are a part of a highly engaged team. Anecdotal remarks included “I love it here” and “Excellent place to work.”

Leading the way to change

Guiding a journey like this requires strong leadership. It is vital for leaders to allow sufficient time for staff to examine their current processes and compare them to what they visualize for the future. Leadership also must have resources and time necessary to accomplish those process improvement goals.

Leadership needs to recognize that every concern, complaint, or suggestion presents an opportunity to improve. Framing the complaint into an opportunity to improve helps lessen feelings of discouragement when staff is unable to meet the needs of patients and physician colleagues.

It is also important to enlist the assistance of a seasoned facilitator who sets a tone of trust, openness, and collaboration in the improvement process. A good facilitator will guide the team to decide upon an impactful, feasible small test of change that will produce a desired improvement.

Facilitating leadership in all staff

Understanding and accepting the skepticism of staff is key to providing opportunities for growth in each staff member. Remember that official and unofficial leaders exist in every team. All staff members—even skeptics—have potential to contribute in meaningful ways. A leader’s ability to tap into each staff member’s potential to participate in the group process is critical to success.

During the Kaizen team event, many behaviors were observed amongst participants. Examples include body language and verbal gestures that displayed skepticism or negativity that things will never change. Other team members involved in the process were open and optimistic and participatory right away. As the Kaizen event evolved, behaviors slowly changed to include more participation from the skeptics.

Through the commitment of the staff to the principles of process improvement, each staff member has gained leadership knowledge, skill, and experience that support their ongoing quest for effective improvement.

Shirley Cahill is a senior strategic process improvement consultant in Cabin John, Maryland, and Rebecca Jackson is the director of perioperative services at Inova Alexandria Hospital in Alexandria Virginia.

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